Page 5 - Policy Holder Claim Guide.43233-39

Colonial Life & Accident Insurance Company | UNIVERSAL CLAIM FORM | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

Claimant name: Claimant SSN:

Section 3 – Employer statement (completed by employer)

Employee name: SSN:
Employee title: Hire date: _______ / _______ / ___________

Average number of scheduled hours per week: Date last worked: _____ / _____ / ________ Date employment terminated: _______ / _______ / ___________

Employee unable to work (Full-time): From: _____ / _____ / ________ To: _____ / _____ / ________ Sick leave was exhausted on: _______ / _______ / ___________

Approved for FMLA (if eligible): From: _____ / _____ / ________ To: _____ / _____ / ________ Was employee at work when accident or sickness occurred? £ Yes £ No
Workers’ compensation carrier
Workers’ compensation claim filed? £ Yes £ No Name: Telephone:

Hourly employee rate: Hours worked per week: Annual salary: If paid on commission basis, attach commission
breakdown for prior 12 months from date last worked.
Do you permit light duty for employee? £ Yes £ No Do you permit partial duty for employee? £ Yes £ No
Expected return to work: Actual return to work: Actual return to work:
______ / ______ / _________ Full-time: ______ / ______ / _________ Part-time: _____ / _____ / ________ Hours per week:_______
Employee’s £ Sitting _____ per hr. £ Walking _____ per hr. £ Climbing stairs/ladders _____ per hr. £ Standing _____ per hr. £ Driving _____ hrs. per day
duties
include: Lifting: £ Less than 15 lbs. £ 15 to 44 lbs. £ More than 45 lbs. Stooping/bending: £ none £ seldom £ frequent
Reaching/pulling/pushing: £ none £ seldom £ frequent Crawling/kneeling: £ none £ seldom £ frequent Repetitive motion: £ none £ seldom £ frequent
Contact for updates on return to work status: Telephone:
Email: Fax:
Fraud warning: Any person who knowingly files a statement of claim containing false or misleading information is subject to
criminal and civil penalties. This includes employer's portions of the claim form.

______________________________________________________________________________________________________ ______________________________
Signature of authorized person Date (MM/DD/YYYY)

Title of authorized person: Employer/company name:
Telephone: Fax: Email:

Section 4A – Hospital confinement/rehabilitation confinement (completed by physician)
Please submit the following with your claim: a copy of the itemized bill showing the admission and discharge dates and the daily room charges.
If you are unable to provide billing statements, please have your doctor complete and sign the claim form.

Diagnosis/ICD codes: Diagnostic procedure date: Diagnostic procedure code/description:
_______ / _______ / __________
Hospital: Telephone:
Address: City: State: ZIP:
Admitting physician: Telephone:
Address: City: State: ZIP:
Treating physician: Telephone:
Address: City: State: ZIP:
£ Hospital confinement and/or £ Observation Room
Admission date: _______ / _______ / __________ Time:________ £ AM £ PM Date released: _______ / _______ / __________ Time:________ £ AM £ PM
Intensive care unit confinement:
Admission date: _______ / _______ / __________ Time:________ £ AM £ PM Date released: _______ / _______ / __________ Time:________ £ AM £ PM
Rehabilitation unit confinement:
Admission date: _______ / _______ / __________ Time:________ £ AM £ PM Date released: _______ / _______ / __________ Time:________ £ AM £ PM
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 4 | ColonialLife.com | 4-19 | 08727-60